In conversation with Professor John Stradling

Tuesday, February 9, 2016

John Stradling, MD, FRCP, Emeritus Professor of respiratory medicine, talks to Respiratory Futures about his article in January's issue of the British Journal of General Practice. He discusses why the support of general practitioners and their staff is fundamental to fast diagnosis and management of Obstructive Sleep Apnoea Syndrome (OSAS), particularly in commercial drivers.

Professor Stradling is a member of the OSA Partnership Group which last year launched a Four Week Wait campaign to raise awareness of the concerns felt by commercial drivers with OSAS and the impact of these drivers not risking coming forward. The Group has proposed fast tracking this group of patients which it is believed will help solve this problem.

Hi John. Welcome to Respiratory Futures, we're very keen to hear more about the OSA Partnership Group. How did it originate?

The OSA Partnership Group has brought together healthcare professionals, patient groups, organisations representing the commercial vehicle sector and those interested in health and safety at work, as well as the relative of the victim of a fatal road traffic accident caused by a driver with untreated sleep apnoea.

The Group was established to raise awareness of Obstructive Sleep Apnoea (OSA) and to address the road safety issues associated with the condition when there are symptoms that include excessive daytime sleepiness, OSA Syndrome (OSAS).

We know that this is a very sensitive area, particularly for vocational drivers who are often naturally concerned about the risk of losing their licence, and as a result, their livelihood. As a Group, we work towards making it easier for these drivers to come forward. The alternative is that they ignore their symptoms and do not get the treatment needed, with potential impact on their health and, the worse-case scenario, a fatal road traffic accident.

We're here to talk specifically about the Four Week Wait initiative - is this the group's first collaboration?

In addition to our Four Week Wait campaign, the Partnership Group has been involved in a number of initiatives. In particular, we have worked with the DVLA in an attempt to clarify what drivers with OSA have to do. As mentioned, this is a very sensitive area so it is an ongoing project to ensure that the process is straightforward and that patients are not discouraged from coming forward.

We know that this is a very sensitive area, particularly for vocational drivers who are [...] concerned about the risk of losing their licence, and as a result, their livelihood.

Another project has involved working with the Freight Transport Association (FTA) to produce a driver-training module about OSA that can be included in the annual training that such drivers have to undertake. The FTA were sufficiently concerned about the importance of OSA that they have made the training module, and associated literature, free to anyone running such a training program.

Moving forward, we’re looking at incentives to encourage fleet operators to be more supportive of drivers with OSA symptoms and also we’re hoping to get involved with NICE’s review of clinical guidelines on OSA.

What prompted this latest campaign and is anyone championing it beyond your immediate partners?

The Sleep Apnoea Trust (SATA) runs a helpline and have received calls from drivers who are worried about coming forward for fear of what could happen to their license and, as a result, livelihood. Furthermore, medical members in our partnership have also heard about these anxieties from patients. The FTA undertook a survey of its members which indicated that 98% of fleet operators did not think their drivers would come forward if they suspected they had OSAS due to worries about losing their jobs.

It’s not difficult to diagnose and treat OSA quickly where facilities exist. If such rapid management can be guaranteed, then drivers will be confident to come forward.

Although the OSA partnership is the body pushing hardest over this problem, the British Thoracic Society’s guidance on OSA and driving, clearly states that professional drivers need rapid and sympathetic management if they are to have the confidence to come forward for treatment. NICE has also introduced a Clinical Knowledge Summary that recommends to GPs that, if they suspect a professional driver might have OSAS, they should ensure a rapid referral to the local sleep unit.

Could you tell us a bit more about the benefits of introducing fast tracking for commercial drivers? What's missing from the current system?

Professional drivers quite rightly value their licences; it’s the key to their continued employment. We hear of stories where, because of delays in diagnosis and treatment - sometimes months - licences are being revoked for long periods of time with the result that the patient loses their job. It is not surprising that this makes drivers reluctant to come forward.

In reality, it’s not difficult to diagnose and treat OSA quickly where facilities exist. If such rapid management can be guaranteed, then drivers will be confident to come forward. This is clearly the best of both worlds, not only do the drivers feel better following treatment, but the risk of a road traffic accident is greatly reduced.

So fast tracking is potentially a very positive step. Where is it likely to have the most impact?

Firstly, it will hopefully mean that drivers who risk continued driving, even though they suspected something might be wrong, will instead come forward to get advice and, if necessary, treatment. As a result their symptoms will improve, as will their quality of life, and their chances of having a devastating accident will be greatly reduced.

If we avoid a single accident, and resulting loss of life, our campaign will have been worthwhile.

Although we’re not talking about vast numbers of potential accidents, every accident involving a heavy goods vehicle, and there have already been many due to OSAS, can have major consequences. Therefore if we avoid a single accident, and resulting loss of life, our campaign will have been worthwhile.

This is clearly a serious and longer-term project rather than a quick win ad campaign. How do you know that implementing fast tracking will work?

There are already sleep units that can offer fast tracking for commercial drivers if they know from the GP referral that the patient drives for a living. It’s more an organisational issue and should not involve a significant increase in workload. Indeed Dr Sophie West in Newcastle instituted a fast track system when the OSA Partnership Group first started its campaign, an audit of that service was presented by Sophie at the 2015 BTS winter meeting.

The service was highly successful and showed that fast-tracking was entirely possible, the main delay was in not knowing that a patient was a commercial driver until they came to clinic. Thus local referral guidelines need to highlight that this information must come with the referral. This is something that the OSA Partnership Group will pick up on in order to communicate to GPs the importance of mentioning a patient’s dependence on driving in referral process.

In addition to your successes to date, have there been any surprises and what do you hope to achieve next?

The main surprise has been the willingness and enthusiasm with which many organisations have supported us and been prepared to help. For example we are working with the RAC which has a large number of fleet operators and drivers it can communicate with. We are hoping that their initiatives will be taken up by similar organisations.

However, we have been disappointed that the NHS seems to have no mechanism whereby all commissioners of health services can be advised to ask their local services to provide certain specific facilities, such as fast tracking commercial drivers with suspected OSAS as this would have been the most effective way to introduce the Four Week Wait programme nationally.

Could you explain a little about how the Four Week Wait campaign fits into the NICE review of clinical guidelines of sleep disorders?

Universal recommendations only seem to come via NICE technology appraisals and clinical guidelines. The technology appraisal of CPAP some years ago was highly influential in improving the availability of treatment for OSA because technology appraisals are essentially compulsory. However this only applies once OSA has been diagnosed! If diagnostic services are poor then OSA sufferers do not get to the point where the technology appraisal applies.

We understand that NICE will be preparing clinical guidelines on the management of OSA and we hope to be able to ensure that this aspect of relating to commercial drivers is included. However it is likely to be a few years before these appear and we need to try and establish the culture of fast tracking commercial drivers for OSA management before then.

If a clinic is interested in introducing a system, what is their next step?

First, they should ensure that referrals include the right information. Under ‘choose and book’ one can include referral guidelines that the GP needs to respond to along with the actual referral. These could include a requirement to state occupation, concerns over excessive sleepiness, and possibly a phone number to call if the patient is a commercial driver with a licence at risk.

Second, there have to be sleep study slots, and CPAP initiation slots kept free for the week or two ahead. Although these may get ‘wasted’ if there doesn’t happen to be a vocational driver that week, many units keep a list of patients prepared to come in at a moment’s notice if a cancellation or spare space become available and hence the space is not wasted. It should not lead to a significant increase in sleep studies or CPAP initiations per unit, just a minor re-engineering of the service.

Sophie West’s extract is a good point of reference for any clinic interested in finding out where to start.

John, thanks very much for speaking with us.

Contact details:

More information about the OSA Partnership Group's Four Week Wait campaign can be found via their Programme page here.